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Levin G, Schwartz A, Horesh N, Alcalay M, Ram E, Meyer R. Predelivery sonographic predictors of obstetric anal sphincter injury among nulliparous women. Int J Gynaecol Obstet 2024; 165:801-805. [PMID: 38009463 DOI: 10.1002/ijgo.15257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE Data available at admission to delivery of nulliparous has rarely been investigated for prediction of obstetric anal sphincter injury (OASI). The aim of the present study was to study risk factors for OASI in nulliparous based on information available at admission. METHODS A retrospective study of all nulliparous women undergoing labor, during March 2011 to January 2021 was performed. We compared women with OASI following delivery to those without by univariate and multivariable regression. RESULTS A total of 30 262 deliveries were included and 4181 (13.4%) of those were delivered by an emergent cesarean delivery. OASI followed 453 (1.5%) deliveries. Women in the OASI group were younger 29 ± 4.4 versus 30 ± 4.8, P = 0.001. In a multivariable regression analysis, higher sonographic estimated fetal weight was positively associated with OASI occurrence (aOR, 95% CI: 1.13 [1.00-1.29]). Maternal age was inversely associated with OASI occurrence (adjusted odds ratio [aOR], 95% confidence interval [CI] 0.95 [0.92-0.97]). CONCLUSION Sonographic fetal weight estimation is an independent risk factor for OASI occurrence that may be available at admission for delivery among nulliparous women.
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Affiliation(s)
- Gabriel Levin
- The Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Anat Schwartz
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nir Horesh
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Department of Surgery and Transplantation, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Menachem Alcalay
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Edward Ram
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Cohen WR, Friedman EA. The second stage of labor. Am J Obstet Gynecol 2024; 230:S865-S875. [PMID: 38462260 DOI: 10.1016/j.ajog.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 03/12/2024]
Abstract
The second stage of labor extends from complete cervical dilatation to delivery. During this stage, descent and rotation of the presenting part occur as the fetus passively negotiates its passage through the birth canal. Generally, descent begins during the deceleration phase of dilatation as the cervix is drawn upward around the fetal presenting part. The most common means of assessing the normality of the second stage of labor is to measure its duration, but progress can be more meaningfully gauged by measuring the change in fetal station as a function of time. Accurate clinical identification and evaluation of differences in patterns of fetal descent are necessary to assess second stage of labor progress and to make reasoned judgments about the need for intervention. Three distinct graphic abnormalities of the second stage of labor can be identified: protracted descent, arrest of descent, and failure of descent. All abnormalities have a strong association with cephalopelvic disproportion but may also occur in the presence of maternal obesity, uterine infection, excessive sedation, and fetal malpositions. Interpretation of the progress of fetal descent must be made in the context of other clinically discernable events and observations. These include fetal size, position, attitude, and degree of cranial molding and related evaluations of pelvic architecture and capacity to accommodate the fetus, uterine contractility, and fetal well-being. Oxytocin infusion can often resolve an arrest or failure of descent or a protracted descent caused by an inhibitory factor, such as a dense neuraxial block. It should be used only if thorough assessment of fetopelvic relationships reveals a low probability of cephalopelvic disproportion. The value of forced Valsalva pushing, fundal pressure, and routine episiotomy has been questioned. They should be used selectively and where indicated.
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Affiliation(s)
- Wayne R Cohen
- Department of Obstetrics and Gynecology, The University of Arizona College of Medicine, Tucson, AZ.
| | - Emanuel A Friedman
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA
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Park M, Wanigaratne S, D'Souza R, Geoffrion R, Williams S, Muraca GM. Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis. AJOG GLOBAL REPORTS 2024; 4:100296. [PMID: 38283323 PMCID: PMC10820309 DOI: 10.1016/j.xagr.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
OBJECTIVE Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship. DATA SOURCES MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies. STUDY ELIGIBILITY CRITERIA Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations. METHODS Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity. Results A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting. Conclusion Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
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Affiliation(s)
- Meejin Park
- Faculty of Health Sciences, Department of Global Health, McMaster University, Hamilton, Ontario, Canada (Ms Park)
| | - Susitha Wanigaratne
- Edwin S.H. Leong Centre for Healthy Children, SickKids Research Institute, Toronto, Ontario, Canada (Dr Wanigaratne)
| | - Rohan D'Souza
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (Dr Geoffrion)
| | - Sarah Williams
- Department of Anthropology, University of Connecticut, Mansfield, CT (Dr Williams)
| | - Giulia M. Muraca
- Faculty of Health Sciences, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Faculty of Health Sciences, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (Drs D'Souza and Muraca)
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden (Dr Muraca)
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Hu Y, Lu H, Huang Q, Ren L, Wang N, Huang J, Yang M, Cao L. Risk factors for severe perineal lacerations during childbirth: A systematic review and meta‐analysis of cohort studies. J Clin Nurs 2022. [PMID: 35791260 DOI: 10.1111/jocn.16438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/24/2022] [Accepted: 06/20/2022] [Indexed: 12/28/2022]
Affiliation(s)
- Yinchu Hu
- School of Nursing Peking University Beijing China
| | - Hong Lu
- School of Nursing Peking University Beijing China
| | - Qifang Huang
- School of Nursing Peking University Beijing China
| | - Lihua Ren
- School of Nursing Peking University Beijing China
| | - Na Wang
- School of Nursing Capital Medical University Beijing China
| | - Jing Huang
- School of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care King's College London London UK
| | - Minghui Yang
- Department of Obstetrics and Gynecology First Affiliated Hospital of Kunming Medical University Kunming China
| | - Linlin Cao
- Department of Obstetrics and Gynecology Peking University Third Hospital Beijing China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital) Beijing China
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Corbett GA, Dicker P, Daly S. Onset and outcomes of spontaneous labour in low risk nulliparous women. Eur J Obstet Gynecol Reprod Biol 2022; 274:142-147. [PMID: 35640443 DOI: 10.1016/j.ejogrb.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/14/2022] [Accepted: 05/12/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The objective of this study was to: 1. Establish the median gestational age of spontaneous labour for low-risk nulliparas. 2. Examine the variation in mode of delivery and short-term neonatal outcomes with gestation at onset of spontaneous labour. STUDY DESIGN This is a retrospective observational cohort study conducted at a tertiary obstetric unit. The study population was 12, 323 low risk nulliparous women with singleton pregnancies who experienced spontaneous onset of labour. The study period was over seven years, from Jan 1st 2011 to 31st Dec 2017. Exclusion criteria were multiparity, multi-fetal pregnancy, booking after 14 weeks gestation, antepartum or intrapartum death, or any obstetric or fetal indication for delivery with the exception of post-maturity. Gestation of onset of spontaneous labour, demographic variables and maternal and neonatal outcomes were collected. The primary outcome was median gestational age at onset of spontaneous labour and its distribution at term. Secondary outcomes were mode of delivery and neonatal outcomes including low-apgar score and NICU admission. RESULTS 12, 323 patients were eligible for inclusion. Median gestation for onset of labour was 40.1 weeks gestation, with 80.5% of spontaneous labour occurs by 41 + 0 weeks gestation. The risk of assisted delivery (RR 1.32, 95% CI 1.23 - 1.42), caesarean section (RR 2.17, 95% CI 1.88-2.51) and low-apgar scores (RR 3.13 95% CI 1.50-6.55) increased significantly with spontaneous labour after 41 weeks' gestation. CONCLUSIONS Nulliparous women with low-risk pregnancies are most likely to experience spontaneous labour between 40 + 0 and 40 + 6. 80.5% of spontaneous labour occurred by 41 + 0 weeks gestation. Assisted vaginal delivery, caesarean section and low-apgar scores were significantly more likely with spontaneous labour after 41 weeks' gestation.
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Affiliation(s)
- Gillian A Corbett
- Department of Obstetrics and Gynaecology, The Coombe Women and Infants' University Hospital, Dublin, Ireland.
| | - Patrick Dicker
- Departments of Epidemiology and Public Health Medicine and Obstetrics and Gynaecology, Royal College of Surgeons, Ireland
| | - Sean Daly
- Department of Obstetrics and Gynaecology, The Coombe Women and Infants' University Hospital, Dublin, Ireland
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Stairs J, Brown MM, Smith A, Woolcott C. Association between second stage of labour length and risk of obstetrical anal sphincter injury in nulliparous women: a population-based retrospective cohort study. Int Urogynecol J 2022; 33:1583-1590. [PMID: 35020035 DOI: 10.1007/s00192-021-05070-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetrical anal sphincter injury (OASIS) is a common consequence of vaginal delivery in nulliparas and carries the risk of short- and long-term morbidity. The objective of this study was to estimate the association between the duration of the second stage of labour and OASIS risk. METHODS A population-based, retrospective cohort of nulliparas delivering singleton, vertex, non-anomalous fetuses at term in Nova Scotia, Canada, from 2005 to 2019, were identified using the Nova Scotia Atlee Perinatal Database. Poisson regression models were used to estimate risk ratios (RR) with robust 95% confidence intervals (CI) adjusting for confounding variables to investigate the association between the length of the second stage and OASIS in the entire cohort and in operative vaginal deliveries. RESULTS Of 36,662 participants, 7.6% sustained an OASIS (6.8% third-degree, 0.8% fourth-degree tear). The proportion of participants who sustained an OASIS increased over the study period. For each 30-min increase in the length of second stage, the OASIS risk increased by 11% (RR 1.11, 95% CI 1.10-1.12). When stratified by mode of delivery, second stage length ≥ 90 min was associated with an increased OASIS risk in spontaneous (RR 1.35, 95% CI 1.15-1.58) and vacuum-assisted vaginal deliveries (RR 1.42, 95% CI 1.11-1.81). In forceps-assisted vaginal deliveries, OASIS risk was increased, with shorter and longer durations of the second stage. CONCLUSION Increasing length of the second stage of labour was associated with increasing risk of OASIS overall, but the association was heterogeneous between modes of delivery. Length of the second stage should be considered in counseling about OASIS risk.
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Affiliation(s)
- Jocelyn Stairs
- Division of Urogynaecology, Department of Obstetrics and Gynaecology, Dalhousie University, 5850/5980 University Avenue, P.O. Box 9700, Halifax, Nova Scotia, B3K 6R8, Canada.
| | - Mary Margaret Brown
- Perinatal Epidemiology Research Unit, Departments of Pediatrics and Obstetrics & Gynaecology, Dalhousie University, Nova Scotia, Canada
| | - Anita Smith
- Division of Urogynaecology, Department of Obstetrics and Gynaecology, Dalhousie University, 5850/5980 University Avenue, P.O. Box 9700, Halifax, Nova Scotia, B3K 6R8, Canada
| | - Christy Woolcott
- Perinatal Epidemiology Research Unit, Departments of Pediatrics and Obstetrics & Gynaecology, Dalhousie University, Nova Scotia, Canada
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Meyer R, Schwartz A, Horesh N, Alcalay M, Ram E, Levin G. A dynamic prediction score for obstetric anal sphincter injury among nulliparous women delivering vaginally. Int J Gynaecol Obstet 2021; 157:271-276. [PMID: 33930180 DOI: 10.1002/ijgo.13730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop a risk score for obstetric anal sphincter injury (OASI) occurrence among nulliparous women delivering vaginally, based on data available at admission for delivery and as labor progresses. METHODS A retrospective study of all nulliparous women who delivered vaginally between March 2011 and January 2021. Characteristics were compared between OASI and no-OASI groups. Multivariable analyses were performed to identify independent risk factors for OASI occurrence. RESULTS OASI occurred in 453 (1.7%) of 26 081 women who met the inclusion criteria. The following variables were independently associated with OASI: maternal height (adjusted odds ratio [aOR] 0.97, 95% confidence interval (CI) 0.95-0.99), hypertensive disorders (aOR 1.74, 95% CI 1.03-2.95), sonographic fetal weight estimation (aOR 1.00, 95% CI 1.00-1.00), second-stage duration (aOR 1.00, 95% CI 1.00-1.00), occiput posterior position (aOR 2.87, 95% CI 1.79-4.62), and episiotomy performance (aOR 0.63, 95% CI 0.47-0.84). In a risk score based on variables available at admission for delivery, the presence of two factors was associated with 4.3% OASI risk. Upon incorporating intrapartum variables, the presence of two risk factors was associated with 2.9% OASI rate. CONCLUSION A dynamic risk score for OASI occurrence based on data available at admission for delivery and as delivery progresses can assist in counseling regarding OASI risk. A dynamic risk score for obstetric anal sphincter injury occurrence based on data available at admission for delivery and intrapartum was developed.
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Affiliation(s)
- Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Schwartz
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nir Horesh
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Department of Surgery and Transplantation, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Menachem Alcalay
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Urogynecology Unit, The Department of Obstetrics and Gynecology, Baruch Padeh-Poria Medical Center, Tiberias, Israel.,The Faculty of Medicine at Galille, Bar-Ilan University, Ramat Gan, Israel
| | - Edward Ram
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Department of Surgery and Transplantation, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Nolan CE, O'Leary BD, Ciprike V. Is the older perineum a safer perineum? Risk factors for obstetric anal sphincter injury. Ir J Med Sci 2020; 190:693-699. [PMID: 32918679 DOI: 10.1007/s11845-020-02358-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Obstetric anal sphincter injury (OASI) is the most common cause of anal incontinence. Identifying risk factors may facilitate change in labour and delivery practice, potentially reducing the risk. The objective of this study is to identify maternal, foetal and intrapartum risk factors for OASI in a regional hospital. METHOD We conducted a retrospective analysis of vaginal deliveries over a 10-year period (2008-2017). Anal sphincter injury was diagnosed by an experienced clinician and classified according to RCOG recommendations. A multiple logistic regression model was created using the presence of OASI as the dependent variable. Coefficients were adjusted for relevant maternal, foetal and intrapartum risk factors. RESULTS During the study period, there were 23,887 vaginal deliveries. Of these births, 18,550 were spontaneous (77.66%), 3746 vacuum-assisted (15.68%), 1196 forceps (5.01%) and 395 sequential instrumental deliveries (1.65%). The overall rate of OASI was 1.76%, with an upward trend seen in nulliparous mothers. Significant factors that increased the risk of OASI were nulliparity, Asian ethnicity, delivery by forceps or sequential instruments, and shoulder dystocia. Vacuum delivery did not significantly increase risk. CONCLUSION Maternal age ≥ 35 years confers a protective effect after adjusting for parity, birth weight and mode of delivery. Given the context of an ageing reproductive population, additional research is required to investigate the impact of maternal age on anal sphincter injury.
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Affiliation(s)
- Ciara E Nolan
- Department of Obstetrics and Gynaecology, Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland.
| | - Bobby D O'Leary
- Department of Obstetrics and Gynaecology, Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland
| | - Vineta Ciprike
- Department of Obstetrics and Gynaecology, Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland
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Pergialiotis V, Bellos I, Antsaklis A, Papapanagiotou A, Loutradis D, Daskalakis G. Maternal and neonatal outcomes following a prolonged second stage of labor: A meta-analysis of observational studies. Eur J Obstet Gynecol Reprod Biol 2020; 252:62-69. [PMID: 32570187 DOI: 10.1016/j.ejogrb.2020.06.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 01/03/2023]
Abstract
Several articles investigated the impact of prolonged second stage of labor on maternal and neonatal outcomes; however, strict consensus is still lacking. The purpose of the present meta-analysis is to investigate risk factors that contribute to the pathophysiology of prolonged labor as well as effect sizes of maternal and neonatal morbidity. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar database. Observational studies (prospective and retrospective) were considered eligible for inclusion in the present meta-analysis. To minimize the possibility of article losses we avoided language, country and date restrictions. Meta-analysis was performed with the RevMan 5.3 and secondary analysis with Rstudio. Overall, 13 studies were included in the present systematic review that comprised 337.845 parturient. Prolonged second stage was associated with higher odds of postpartum hemorrhage, chorioamnionitis, endometritis, postpartum fever and obstetric anal sphincter injury. Persistent occiput posterior position and shoulder dystocia were also more prevalent compared to women with normal duration of the second stage. The need for admission to the neonatal intensive care unit was higher as well as the risk of developing neonatal sepsis. On the other hand, the odds of perinatal death were comparable among cases with prolonged and normal duration of the second stage. The results of the present meta-analysis clearly indicate that deliveries following a prolonged second stage of labor are at increased risk of maternal and neonatal complications. The presented effect estimates can be used in current clinical practice during patient counseling.
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Affiliation(s)
- Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece; 1(st)department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece.
| | - Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece
| | - Aris Antsaklis
- 1(st)department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Angeliki Papapanagiotou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- 1(st)department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - George Daskalakis
- 1(st)department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
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10
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Dall’Asta A, Angeli L, Masturzo B, Volpe N, Schera GBL, Di Pasquo E, Girlando F, Attini R, Menato G, Frusca T, Ghi T. Prediction of spontaneous vaginal delivery in nulliparous women with a prolonged second stage of labor: the value of intrapartum ultrasound. Am J Obstet Gynecol 2019; 221:642.e1-642.e13. [PMID: 31589867 DOI: 10.1016/j.ajog.2019.09.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/22/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND A limited number of studies have addressed the role of intrapartum ultrasound in the prediction of the mode of delivery in women with prolonged second stage of labor. OBJECTIVE The objective of the study was to evaluate the role of transabdominal and transperineal sonographic findings in the prediction of spontaneous vaginal delivery among nulliparous women with prolonged second stage of labor. STUDY DESIGN This was a 2-center prospective study conducted at 2 tertiary maternity units. Nulliparous women with a prolonged active second stage of labor, as defined by active pushing lasting more than 120 minutes, were eligible for inclusion. Transabdominal ultrasound to evaluate the fetal head position and transperineal ultrasound for the measurement of the midline angle, the head-perineum distance, and the head-symphysis distance were performed in between uterine contractions and maternal pushes. At transperineal ultrasound the angle of progression was measured at rest and at the peak of maternal pushing effort. The delta angle of progression was defined as the difference between the angle of progression measured during active pushing at the peak of maternal effort and the angle of progression at rest. The sonographic findings of women who had spontaneous vaginal delivery vs those who required obstetric intervention, either vacuum extraction or cesarean delivery, were evaluated and compared. RESULTS Overall, 109 were women included. Spontaneous vaginal delivery and obstetric intervention were recorded in 40 (36.7%) and 69 (63.3%) patients, respectively. Spontaneous vaginal delivery was associated with a higher rate of occiput anterior position (90% vs 53.2%, P < .0001), lower head-perineum distance and head-symphysis distance (33.2 ± 7.8 mm vs 40.1 ± 9.5 mm, P = .001, and 13.1 ± 4.6 mm vs 19.5 ± 8.4 mm, P < .001, respectively), narrower midline angle (29.6° ± 15.3° vs 54.2° ± 23.6°, P < .001) and wider angle of progression at the acme of the pushing effort (153.3° ± 19.8° vs 141.8° ± 25.7°, P = .02) and delta-angle of progression (17.3° ± 12.9° vs 12.5° ± 11.0°, P = .04). At logistic regression analysis, only the midline angle and the head-symphysis distance proved to be independent predictors of spontaneous vaginal delivery. More specifically, the area under the curve for the prediction of spontaneous vaginal delivery was 0.80, 95% confidence interval (0.69-0.92), P < .001, and 0.74, 95% confidence interval (0.65-0.83), P = .002, for the midline angle and for the head-symphysis distance, respectively. CONCLUSION Transabdominal and transperineal intrapartum ultrasound parameters can predict the likelihood of spontaneous vaginal delivery in nulliparous women with prolonged second stage of labor.
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11
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Incidence and risk factors for obstetric anal sphincter ruptures, OASIS, following the introduction of preventive interventions. A retrospective cohort study from a Norwegian hospital 2012-2017. SEXUAL & REPRODUCTIVE HEALTHCARE 2019; 22:100460. [PMID: 31491687 DOI: 10.1016/j.srhc.2019.100460] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/05/2019] [Accepted: 08/20/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A decrease of obstetric anal sphincter injuries (OASIS) was observed after preventive interventions were implemented at a Norwegian university hospital. The aim was to investigate whether the improvement had sustained over the following years. MATERIALS AND METHODS We performed a retrospective cohort study of 18 258 singleton vaginal cephalic births, ≥37 + 0 weeks of gestation during 2012-2017, examining data from the hospital's birth journals and separate registration forms. Interventions to prevent OASIS were implemented in 2011, and training in practical skills was repeated each year. MAIN OUTCOME MEASURES The main outcome was OASIS (n = 377). RESULTS Frequency of OASIS overall decreased from 3.6% prior to 2011 to 2.1% after the intervention and sustained at that level throughout the study period. A trend of fewer OASIS among spontaneous deliveries, decreasing from 2.1% to 1.2% (p = 0.01) was observed, but no trend was seen for instrumental deliveries (p = 0.37), where the incidence fluctuated between 4.0% and 9.3% with an average of 6.5%. Primiparity, increased maternal age and increased fetal head circumference were associated with more OASIS in spontaneous deliveries. In instrumental deliveries, primiparity, occiput posterior position and increased fetal head circumference were associated with more OASIS, whilst episiotomy was associated with fewer OASIS. CONCLUSION The incidence of obstetric anal sphincter injuries maintained at a similar level of around 2.1% during the six following years after introducing preventive interventions. Regularly repetition and practical training seemed to be effective.
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Lessons Learned From a Review of Malpractice Litigations Involving Obstetric Anal Sphincter Injury in the United States. Female Pelvic Med Reconstr Surg 2019; 26:249-258. [DOI: 10.1097/spv.0000000000000687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Single prior caesarean section and risk of anal sphincter injury. Int Urogynecol J 2018; 30:959-964. [PMID: 30377707 DOI: 10.1007/s00192-018-3797-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Injury to the anal sphincter at vaginal delivery remains the leading cause of faecal incontinence in women. Previous studies reported an increased incidence of obstetric anal sphincter injury (OASI) in women attempting vaginal birth after caesarean section (VBAC). The aim of the paper was to establish whether women in their second pregnancy, with one previous uterine scar, are at a higher risk of OASI compared with nulliparous women. METHODS All primiparous and secundiparous women with a previous caesarean section who delivered from 2008 to 2017 were analysed in a single-centre retrospective study. The primary endpoint was OASI. Labour characteristics in both groups were compared, and a multiple regression model was created. RESULTS There were 8573 vaginal deliveries of nulliparous women and 3453 deliveries of women in their second pregnancy with a previous caesarean section, of whom 550 had a successful VBAC. There was no significant difference in the rate of OASI between primiparous women and those who had a successful VBAC: 3.5% (297/8573) versus 3.1% (17/550), P = 0.730). Foetal macrosomia (>4 kg) and forceps delivery were risk factors for sphincter injury, while episiotomy and epidural anaesthesia were protective. CONCLUSIONS VBAC does not confer an increased risk of OASI after a first delivery by caesarean section when compared with nulliparous women. The rate of successful VBAC may be contributory and suggests that the risk conferred by VBAC may be unit-specific. Unit and national-level audit is necessary to investigate this risk further.
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An obstetric sphincter injury risk identification system (OSIRIS): is this a clinically useful tool? Int Urogynecol J 2016; 28:367-374. [PMID: 27589856 PMCID: PMC5331086 DOI: 10.1007/s00192-016-3125-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 08/02/2016] [Indexed: 11/09/2022]
Abstract
Introduction and hypothesis To establish the contribution of maternal, fetal and intrapartum factors to the risk of incidence of obstetric anal sphincter injuries (OASIS) and assess the feasibility of an OASIS risk prediction model based on variables available to clinicians prior to birth. Methods This was a population-based, retrospective cohort study using single-site data from the birth database of Aarhus University Hospital, Denmark. The participants were all women who had a singleton vaginal birth during the period 1989 to 2006. Univariate and multivariate logistic regression analyses were performed using multiple imputations for missing data and internally validated using bootstrap methods. The main outcome measures were the contributions of maternal, fetal and intrapartum events to the incidence of OASIS. Results A total of 71,469 women met the inclusion criteria, of whom 1,754 (2.45 %) sustained OASIS. In the multivariate analysis of variables known prior to birth, maternal age 20 – 30 years (OR 1.65, 95 % CI 1.44 – 1.89) and ≥30 years (OR 1.60, 95 % CI 1.39 – 1.85), occipitoposterior fetal position (OR 1.34, 95 % CI 1.06 – 1.70), induction/augmentation of labour (OR 1.46, 95 % CI 1.32 – 1.62), and suspected macrosomia (OR 2.20, 95 % CI 1.97 – 2.45) were independent significant predictors of OASIS, with increasing parity conferring a significant protective effect. The ‘prebirth variable’ model showed a 95 % sensitivity and a 24 % specificity in predicting OASIS with 1 % probability, and a 3 % sensitivity and a 99 % specificity in predicting OASIS with a 10 % probability. Conclusions Our model identified several significant OASIS risk factors that are known prior to actual birth. The prognostic model shows potential for ruling out OASIS (high sensitivity with a low risk cut-off value), but is not useful for ruling in the event. Electronic supplementary material The online version of this article (doi:10.1007/s00192-016-3125-2) contains supplementary material, which is available to authorized users.
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Meister MR, Cahill AG, Conner SN, Woolfolk CL, Lowder JL. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol 2016; 215:310.e1-7. [PMID: 26902989 DOI: 10.1016/j.ajog.2016.02.041] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/21/2016] [Accepted: 02/16/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. OBJECTIVE The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. STUDY DESIGN This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. RESULTS Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury. CONCLUSIONS Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks.
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Conséquences maternelles de la prolongation des efforts expulsifs. ACTA ACUST UNITED AC 2016; 45:184-91. [DOI: 10.1016/j.jgyn.2015.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 07/06/2015] [Accepted: 07/13/2015] [Indexed: 11/23/2022]
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Kapoor DS, Thakar R, Sultan AH. Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions. Int Urogynecol J 2015; 26:1725-34. [PMID: 26044511 DOI: 10.1007/s00192-015-2747-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Modification of various risk factors and anatomical considerations have been reported to reduce the rate of OASI. METHODS A PubMed search (1989-2014) of studies and systematic reviews on risk factors for OASI. RESULTS Perineal distension (stretching) of 170 % in the transverse direction and 40 % in the vertical direction occurs at crowning, leading to significant differences (15-30°) between episiotomy incision angles and suture angles. Episiotomies incised at 60° achieve suture angles of 43-50°; those incised at 40° result in a suture angle of 22°. Episiotomies with suture angles too acute (<30°) and too lateral (>60°) are associated with an increased risk of OASI. Suture angles of 40-60° are in the safe zone. Clinicians are poor at correctly estimating episiotomy angles on paper and in patients. Sutured episiotomies originating 10 mm away from the midline are associated with a lower rate of OASIs. Compared to spontaneous tears, episiotomies appear to be associated with a reduction in OASI risk by 40-50 %, whereas shorter perineal lengths, perineal oedema and instrumental deliveries are associated with a higher risk. Instrumental deliveries with mediolateral episiotomies are associated with a significantly lower OASI risk. Other preventative measures include warm perineal compresses and controlled delivery of the head. CONCLUSIONS Relieving pressure on the central posterior perineum by an episiotomy and/or controlled delivery of the head should be important considerations in reducing the risk of OASI. Episiotomies should be performed 60° from the midline. Prospective studies should evaluate elective episiotomies in women with a short perineal length and application of standardised digital perineal support.
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Affiliation(s)
- Dharmesh S Kapoor
- Department of Obstetrics and Gynaecology, Royal Bournemouth Hospital, Bournemouth, UK.
| | - Ranee Thakar
- Croydon University Hospital, Croydon, UK. .,St George's University of London, London, UK.
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